7 / 32
Blue Open Access POS
– Small and Large Groups
OAP5 1K/90 A Benefit Summary
All benefits are subject to the calendar year deductible, except those with in-network copayments, unless otherwise noted.
All calendar year maximums are combined between in-network and out-of-network.
In addition to copayments, members are responsible for deductibles and any applicable coinsurance.
Members are also responsible for all costs over the plan maximums.
Some services may require pre-certification before services are covered by the Plan.
When using out-of-network providers, members are responsible for any difference between the Maximum Allowed Amount and
the amount the provider actually charges, as well as any copayments, deductibles and/or applicable coinsurance.
Deductibles, Coinsurance and Maximums
In-network Benefit Level
Out-of-Network Benefit Level
Calendar Year Deductible
*
▪ Individual
▪ Family
$1,000
$3,000
$2,000
$6,000
Coinsurance
Member pays 10%
Plan pays 90%
Member pays 40%
Plan pays 60%
Calendar Year Out-of-Pocket Maximum
*
(includes calendar year deductible)
▪ Individual
▪ Family
$4,000
$12,000
$8,000
$24,000
Lifetime Maximum
Unlimited
Unlimited
*Deductibles and out-of-pocket maximums are added separately for in-network and out-of-network services. One family member may reach his or her
Individual deductible and be eligible for coverage on health care expenses before other family members. Each family member’s deductible amount also goes
toward the Family deductible and out-of-pocket maximum. Not everyone has to meet his or her deductible and out-of-pocket maximum for the family to
meet theirs. When the Family deductible is met, all family members can access coverage for health care expenses.
The following do not apply to out-of-pocket maximums: copayment amounts, non-covered items and any member cost shares for pharmacy services.
Covered Services
In-network Benefit Level
Out-of-Network Benefit Level
Preventive Care Services for Children and Adults
(preventive care services that meet the requirements of federal and state
law, including certain screenings, immunizations and physician visits)
▪ Well-child care, immunizations
▪ Periodic health examinations
▪ Annual gynecology examinations
▪ Prostate screenings
Member pays 0%
(not subject to deductible)
Member pays 30% after deductible
(deductible waived through age 5)
Physician Office Visits for Illness and Injury
(including
labs, x-rays, and diagnostic procedures)
▪ Primary Care Physician (PCP
)*
▪ OB/GYN
▪ Specialist Physician
*Also applies to services rendered at Retail Health Clinics
$25 copayment
$25 copayment
$50 copayment
Member pays 40% after deductible
Maternity Physician Services
▪ 1
st
Prenatal visit
▪
Global obstetrical care
(prenatal, delivery and postpartum services)
$25 copayment
Member pays 10% after deductible
Member pays 40% after deductible
Member pays 40% after deductible
Telemedicine Services
$25 PCP copayment or
$50 Specialist copayment
Member pays 40% after deductible
Allergy Services
▪ Office visits, testing and the administration of allergy injections
▪ Allergy injection serum
$25 PCP copayment or
$50 Specialist copayment
Member pays 10% after deductible
Member pays 40% after deductible
Member pays 40% after deductible
5